Breast cancer screening guidelines confuse doctors and patients

Breast cancer screening guidelines confuse doctors and patientsThe American College of Obstetricians and Gynecologists (ACOG) recently released their recommendations for breast cancer screening.

Previously, they had recommended a mammogram every 1 to 2 years for women between the ages of 40 to 49.

Now, they recommend more intensive screening:

Due to the high incidence of breast cancer in the US and the potential to reduce deaths from it when caught early, The American College of Obstetricians and Gynecologists (The College) today issued new breast cancer screening guidelines that recommend mammography screening be offered annually to women beginning at age 40. Previous College guidelines recommended mammograms every one to two years starting at age 40 and annually beginning at age 50.

This contradicts the 2009 recommendation from the USPSTF, which recommended an individualized approach and against routine screening for women aged 40-49.

No wonder patients are confused.

In our society, which values tests and generally believes that earlier cancer detection is better care, the ACOG recommendations were met with media acclaim.

Gary Schwitzer, for instance,  points out the bias in CNN’s reporting the guidelines, and specifically takes senior medical correspondent Elizabeth Cohen’s Tweet on the issue to task:

On many occasions that we’ve written about on this blog in recent years, CNN has demonstrated a bias in favor of screening – touting benefits, minimizing harms. Sanjay Gupta’s badgering of US Preventive Services Task Force member Lucy Marion will always stand out in my mind – and in the minds of many of who saw it – as opinionated “attack” journalism that reflects the polarization we often see in politics now creeping (leaping?) into health care and into health care journalism.

As to which guideline to believe, physicians will be divided. I suspect that physicians who practice more strict evidence-based medicine will go with the USPSTF recommendations, while gynecologists will follow their college’s more aggressive recommendations.

Although I’m a proponent of clinical guidelines, obtaining the needed consensus will be difficult. There are too many proverbial cooks in the pot, with every medical society releasing potentially conflicting recommendations and confusing both doctors and patients.

Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitter, and LinkedIn.

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  • http://twitter.com/jodyms Jody Schoger

    Trying to distill this issue into 140-character tweets or even a 2-minute news feature is part of the problem. There is no confusion if one underlying point is clear:  the original USPSTF guidlelines were just that — GUIDELINES for each woman to decide w/her physician based on her history, risk factors, preference, etc. And the ACOG is not made up of oncologists but gynecologists and obstetricians, not really the ones I’d want advising me on cancer screening (other than cervical or ovarian).  

    For a clear read we should take all the data each group is basing their recommendations on (are the different groups using the same data?) and give it to a group of doctoral students in critical analysis.  That way we could eliminate bias.  
    jms

    • http://profiles.yahoo.com/u/66NCFAXDWYB7JVNVNLNIUTCUVU Violetta V

       … the ACOG is not made up of oncologists but gynecologists and
      obstetricians, not really the ones I’d want advising me on cancer
      screening (other than cervical or ovarian).  …

      Actually, it’s epidemiologists who are the most qualified to address the
      benefits and risks of screening. While the oncologists see the
      individual cases, essentially anecdotal information, the epidemiologists
      see the overall picture.

      An oncologist would always be biased towards screening. An oncologist
      would see early cancers that are more treatable vs the suffering of
      people with advanced cancer, but not the fact that a particular early
      cancer was non-agressive to begin with and may not have ever caused any problems if remained undetected or the fact that it’s not clear if screening would’ve made a difference in a particular advanced cancer (and based on the data the probability is higher that it wouldn’t have).

      Epidemiologists see the overall picture. They see the studies and data such as comparisons of breast cancer mortality numbers in screened vs non-screened group, extra early cancers detected in screened group vs subsequent reduction (if any) in advanced cancers. Unfortunately, the data is fairly conflicted for mammograms. Take this recent report from Sweden that supposedly show greater (breast cancer) mortality reduction benefit with mammograms. When they released their previous report, there were publications challenging their calculation method and explaining how they are methods overstating the benefit and minimize the amount of overdiagnosis. Also, Dr Welch pointed out that improvement in treatment since this trial is likely to further reduce the benefits whereas the improvement in screening technology may well increase overdiagnosis.

      Guidelines are good, but ultimately the women have a right to information about both benefits and harms so that they could make their own decision without pressure from their doctors.

  • http://twitter.com/DrEdPullen Edward Pullen

    The recommendation by ACOG is far from an unbiased one.  This will generate office visits and income for their members.  USPSTF looks at the data and tries to give opinions based on the evidence.  Like the PSA debate we are likely making much overdiagnosis in some types of breast cancer, leading to considerable unnecessary, potentially harmful, certainly stressful, and unquestionably expensive care.  Early diagnosis, even in cancer, is not always beneficial, and we need to be careful in our zeal and try to be objective in looking at evidence.  See Kenny Lin’s excellent article on overdiagnosis.  

    • Margalit Gur-Arie

      Dr. Pullen, I am not debating the recommendations from USPSTF, or the ones from ACOG, but I don’t understand how the latter generates office visits for OB/GYN. It may generate income for screening facilities and oncologists, but maybe one more visit for GYN (maybe). Are we saying that $100 is enough money to make physicians support practices that pose danger to their patients?

  • Anonymous

    Yet another physician organizaiton that fails to discuss the issue of overdiagnosis…

  • http://twitter.com/HeartSisters carolyn thomas

    Will ACOG be issuing its collective opinions soon on routine cardiac screening?  How about prostate screening? How about regular vision tests?  And how frequently do they think I should I visit my dentist?

    My understanding of USPSTF recommendations is that without breast screening, 3.5 out of every 1,000 women ages 40 to 49 will
    die of breast cancer in the next 10 years; regular mammography can
    reduce that number to THREE. The task force panel calculated that to
    save one life among women in this age group, 1,900 women must be
    screened annually for 10 years. The other 1,899 women, they determined,
    will receive no benefit from mammography over that period, though they will field 1,330 call-backs for reassessment and 665 breast biopsies, and eight of them will be diagnosed with cancers whose prognosis will not be altered
    by detection via mammogram – either because they would never become
    dangerous or because they are so aggressive that there’s little to be
    done.

    And here’s where simple semantics got a bit fuzzy:  the panel wrestled with the language, finally deciding to “recommend against routine screening mammography” for women in their 40s. The intention was to emphasize the word “routine,” but instead people focused on the word “against”. As task force chair Dr. Ned Calonge puts it:  “No one got beyond that.” 

    But wait.  When Senate
    investigators led by Senator Charles Grassley
    (R-Iowa) asked groups opposed to the USPSTF report to reveal any financial backing they
    receive from the pharmaceutical, medical device and insurance
    industries, they discovered that the most vociferous critics of the new
    breast screening guidelines included top officers at organizations like
    the American College of Radiology and the American Cancer Society,
    which receive substantial funding from the makers of mammography
    machines, including Johnson & Johnson, Siemens and Hologic.

    As in all things, simply follow the money, folks.

  • http://www.facebook.com/people/Jackie-Swenson/100000046998781 Jackie Swenson

    A more pressing issue is the ‘false negative’ result.  Other screening methods need to be offered to the patients besides mammogram as it misses more than 20% of breast cancer incidents.  My recurrence would not have been found had I not alerted the breast surgeon.  Nobody had ever told me about the so-called ‘scar tissue’ on the film.  Because I had been told it was ‘fine’, I accepted the ‘fact’ that I was one of those women who would experience ‘painful’ mammograms’.

    Well, it turned out that the terrible pain during the procedure was caused by a 2 cm+ tumor pressing against my flesh…  It had gone unnoticed (misread) for almost 4 years.